Cyclothymic Disorder (Cyclothymia): Signs, Treatment, Differentiating From Bipolar and Major Depression

Cyclothymic Disorder (Cyclothymia): Navigating the Ups and Downs

Cyclothymic Disorder (Cyclothymia), a chronic mood disorder lesser known than its counterparts like Bipolar Disorder, involves cycling between hypomanic and depressive symptoms. These fluctuations are less severe than the full manic/hypomanic episodes or depressive episodes seen in Bipolar Disorder or Major Depressive Disorder, but can still significantly impact a person’s life. This article provides an in-depth look into the signs and symptoms of Cyclothymic Disorder, discusses the DSM-5 criteria for diagnosis, and explores the available treatment options. We also will go into depth comparing Cyclothymic Disorder with Bipolar Disorder and Major Depressive Disorder (MDD).

Signs and Symptoms of Cyclothymic Disorder

• Mood Fluctuations: Cyclothymic Disorder is characterized by alternating periods of elevated, expansive or irritable mood and depressed mood. These are not as intense or disruptive as those in Bipolar Disorder or MDD but are noticeable and impact daily life.
• Hypomanic Symptoms: During these elevated phases, which do not quite meet criteria for a hypomanic episode, individuals may experience elevated mood, increased energy, inflated self-esteem, decreased need for sleep, and more talkativeness than usual. These episodes are generally less intense than a full manic or hypomanic episode, and by definition cannot be severe enough to have psychotic symptoms or require hospitalization.
• Depressive Symptoms: The depressive phase involves symptoms like low mood, fatigue, feelings of worthlessness, loss of interest in activities, and changes in sleep and appetite. These symptoms are generally not as severe as those seen in Major Depressive Disorder.
• Chronicity: Symptoms persist for at least two years in adults (one year in children and adolescents), with no symptom-free periods lasting longer than two months.

DSM-5 Criteria for Cyclothymic Disorder

According to the DSM-5, Cyclothymic Disorder is diagnosed based on the following criteria:

1. For at least 2 years (at least 1 year in children and adolescents), there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.
2. The hypomanic and depressive periods have been present for at least half the time and have not been without symptoms for more than two months at a time.
3. Criteria for a major depressive, manic, or hypomanic episode have never been met.
4. The symptoms are not better explained by another mental disorder such as schizophrenia, delusional disorder, etc.
5. The symptoms are not attributable to the physiological effects of a substance (a drug of abuse, a medication) or another medical condition.
6. The symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning.

Differentiating Cyclothymic Disorder from Bipolar Disorder

While Cyclothymic Disorder and Bipolar Disorder share similarities, primarily involving mood swings, it’s crucial to understand their distinct differences for accurate diagnosis and treatment. Here’s how they differ:

1. Severity of Mood Episodes: The most significant difference lies in the intensity of the mood episodes. In cyclothymia, the “highs” aren’t quite as high and the “lows” aren’t quite as low. For example, depressive episodes in MDD generally require 5 symptoms to diagnose, whereas there would be less than 5 symptoms in cyclothymia. Manic or hypomanic episodes require elevated mood with 3 accompanying symptoms, while cyclothymia does not have a number of symptoms that have to be met. If there have ever been psychotic symptoms or mental health hospitalizations then by definition cyclothymia cannot be diagnosed.
2. Duration: Cyclothymic Disorder is diagnosed when a pattern of mood cycling that lasts 2 years or longer emerges. This 2 year criteria is not required to diagnosed Bipolar Disorder or MDD. Additionally, hypomanic episodes should last at least 4 days and manic episodes should last at least 1 week, whereas length of hypomanic symptoms is not a factor when diagnosing cyclothymia.
3. Criteria for Episodes: In Bipolar Disorder, individuals experience full manic, hypomanic or major depressive episodes. These episodes are more severe and disruptive compared to Cyclothymic Disorder, where one might experience manic, hypomanic or depressive symptoms but not experience enough symptoms to meet full criteria for an episode. 
4. Functional Impairment: While both disorders can impair functioning, the impact is usually more pronounced in Bipolar Disorder due to the severity of the episodes. Individuals with Cyclothymic Disorder may experience less disruption in their daily lives but still face challenges due to the ongoing nature of their mood fluctuations.
5. Risk of Developing Other Mood Disorders: While these disorders are different, they can be seen as somewhat linked. People with Cyclothymic Disorder have a heightened risk of developing full-blown Bipolar Disorder over time. It’s seen as a potential precursor to Bipolar Disorder, although not everyone with Cyclothymic Disorder will progress to this.

Differentiating Cyclothymic Disorder from Major Depressive Disorder

While Cyclothymic Disorder and Major Depressive Disorder share similarities, primarily involving feeling down and low, it’s again important to understand their differences for diagnosis and treatment. Here’s how Cyclothymia and MDD differ:

1. Presence of Hypomanic Episodes: A defining feature of Cyclothymic Disorder is the presence of manic/hypomanic symptoms, which are absent in MDD. These symptoms in Cyclothymic Disorder are less severe than the full manic or hypomanic episodes seen in Bipolar Disorder but are distinguished from the normal mood by a noticeable change in behavior and energy levels. In contrast, MDD is characterized by a single, predominant mood state – prolonged and persistent depressive episodes, without alternating to manic or hypomanic phases.
2. Duration and Chronicity: Cyclothymic Disorder is a chronic condition marked by at least two years (one year in children and adolescents) of ongoing mood fluctuations. MDD involves discrete depressive episodes, each typically lasting for a minimum of two weeks. In Cyclothymic Disorder, symptoms are present more consistently over a long period, with no symptom-free interval longer than two months.
3. Severity of Symptoms: While both disorders involve depressive symptoms, the severity and impact can differ. The depressive symptoms in Cyclothymic Disorder are generally milder and less incapacitating than those in MDD, which are often severe and can significantly impair daily functioning. To clarify, depressive episodes in MDD generally require 5 symptoms to diagnose, whereas there would be less than 5 symptoms in cyclothymia. Thus, one with the milder depressive symptoms seen in cyclothymia by definition would not meet the full criteria for a major depressive episode.
4. Functional Impairment: Although both conditions can lead to distress and impairment, the impact of MDD is typically more profound in terms of the ability to function in daily life. The depressive episodes in MDD are more debilitating compared to the chronic, but less severe, depressive symptoms of Cyclothymic Disorder.

Treatment Options for Cyclothymic Disorder

• Accurate Diagnosis: As evidenced by a number of sections in this article, cyclothymia overlaps significantly with many commonly diagnosed psychiatric disorders. Thus, it is imperative to get the diagnosis correct in order to direct treatment appropriately. Even Borderline Personality Disorder (BPD), which is not commonly thought of as being related to cyclothymia, can muddy the picture, as 10-20% of those with BPD are estimated to also meet criteria for cyclothymia.
• Psychotherapy: Psychodynamic therapy, Cognitive-behavioral therapy (CBT) and other forms of psychotherapy can be effective in helping individuals live with cyclothymia. Psychoeducation about the diagnosis and coping strategies to manage mood fluctuations can be particularly helpful. Family therapy to education family members about the diagnosis and early warning signs of mania is an important strategy to minimize risk of harm. 
• Medication: While medication management specifically of Cyclothymic Disorder is not well studied due to the low number of people diagnosed with cyclothymia in clinical practice, we do have some general principles that can help in selecting treatment. Conceptualizing cyclothymia as a sort of mild bipolar disorder is helpful in picking medications, where mood stabilizers are typically quite helpful. Like in bipolar, antidepressants are used with caution as they may increase the risk of having a hypomanic or manic episode and converting from Cyclothymic Disorder to Bipolar Disorder.

Wrapping Up Cyclothymic Disorder

Cyclothymic Disorder, with its recurrent mood changes, poses unique challenges. Understanding this disorder is key to managing its symptoms and leading a balanced life. If you or someone you know shows signs of Cyclothymic Disorder, seeking professional help is crucial. Early intervention with appropriate psychotherapy, medication management, and lifestyle changes can make a significant difference. Remember, acknowledging the condition is the first step towards effective management and improved quality of life.